Journal of Foot and Ankle Surgery (Asia Pacific)

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VOLUME 9 , ISSUE 4 ( October-December, 2022 ) > List of Articles


Management in Stage IV Adult-acquired Flatfoot Deformity

Tanarat Hempongphan, Chamnanni Rungprai, Yantarat Sripanich

Keywords : Acquired adult flatfoot, Flatfoot, Flatfoot deformity

Citation Information : Hempongphan T, Rungprai C, Sripanich Y. Management in Stage IV Adult-acquired Flatfoot Deformity. J Foot Ankle Surg Asia-Pacific 2022; 9 (4):172-177.

DOI: 10.5005/jp-journals-10040-1186

License: CC BY-NC 4.0

Published Online: 07-10-2022

Copyright Statement:  Copyright © 2022; The Author(s).


Adult-acquired flatfoot deformity (AAFD) is one of the most common degenerative tendinosis problems of the foot and ankle in the aging population. Tendon dysfunction, which typically occurs in the tibialis posterior tendon, leads to secondary damage of surrounding ligaments. Degeneration of the posterior tibial tendon (PTT) induces a change in this complex, resulting in further deformity of the talonavicular joint. In addition to this deformity, the interosseous ligament of the subtalar joint is also affected, resulting in subtalar subluxation. The advanced stage of the posterior tibialis tendon and deltoid ligament insufficiency with a concurrent valgus deformity results in an abnormal deforming force to the ankle, disruption of the foot, and ankle biomechanics, and the increase in the peak pressure loads. If left untreated, this abnormal condition ultimately leads to arthritic changes of the midfoot, hindfoot, and ankle joints. Adult-acquired flatfoot deformity stage IV is the foot deformity that involved lateral talar tilt deformity of the ankle, which can be subclassified into flexible type (IVA) and fixed type (IVB). This chapter will provide a state-of-the-art understanding of how to deal with patients suffering from the Stage IV AAFD and the outcomes of each treatment method.

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  1. Haddad SLDJ. Pes planus. In: Coughlin MSC, Anderson RB, ed. Mann's surgery of the foot and ankle. 9th ed., Philadelphia, PA: Elsevier Saunders; 2014. pp. 1292–1360.
  2. Deland JT. Adult-acquired flatfoot deformity. J Am Acad Orthop Surg 2008;16(7):399–406. DOI: 10.5435/00124635-200807000-00005
  3. Flores DV, Mejia Gomez C, Fernandez Hernando M, et al. Adult acquired flatfoot deformity: anatomy, biomechanics, staging, and imaging findings. Radiographics 2019;39(5):1437–1460. DOI: 10.1148/rg.2019190046
  4. Frances JM, Feldman DS. Management of idiopathic and nonidiopathic flatfoot. Instr Course Lect 2015;64:429–440.
  5. Smyth NA, Aiyer AA, Kaplan JR, et al. Adult-acquired flatfoot deformity. Eur J Orthop Surg Traumatol 2017;27(4):433–439. DOI: 10.1007/s00590-017-1945-5
  6. Mengiardi B, Pinto C, Zanetti M. Spring Ligament Complex and Posterior Tibial Tendon: MR Anatomy and Findings in Acquired Adult Flatfoot Deformity. Semin Musculoskelet Radiol 2016;20(1):104–115. DOI: 10.1055/s-0036-1580616
  7. Mengiardi B, Zanetti M, Schöttle PB, et al. Spring ligament complex: MR imaging-anatomic correlation and findings in asymptomatic subjects. Radiology 2005;237(1):242–249. DOI: 10.1148/radiol.2371041065
  8. Taniguchi A, Tanaka Y, Takakura Y, et al. Anatomy of the spring ligament. J Bone Joint Surg Am 2003;85(11):2174–2178. DOI: 10.2106/00004623-200311000-00018
  9. Ananthakrisnan D, Ching R, Tencer A, et al. Subluxation of the talocalcaneal joint in adults who have symptomatic flatfoot. J Bone Joint Surg Am 1999;81(8):1147–1154. DOI: 10.2106/00004623-199908000-00010
  10. de Cesar Netto C, Godoy-Santos AL, Saito GH, et al. Subluxation of the Middle Facet of the Subtalar Joint as a Marker of Peritalar Subluxation in Adult Acquired Flatfoot Deformity: A Case-Control Study. J Bone Joint Surg Am 2019;101(20):1838–1844. DOI: 10.2106/JBJS.19.00073
  11. Kunas GC, Probasco W, Haleem AM, et al. Evaluation of peritalar subluxation in adult acquired flatfoot deformity using computed tomography and weightbearing multiplanar imaging. Foot Ankle Surg 2018;24(6):495–500. DOI: 10.1016/j.fas.2017.05.010
  12. Orr JD, Nunley JA 2nd. Isolated spring ligament failure as a cause of adult-acquired flatfoot deformity. Foot Ankle Int 2013;34(6):818–823. DOI: 10.1177/1071100713483099
  13. Vulcano E, Deland JT, Ellis SJ. Approach and treatment of the adult acquired flatfoot deformity. Curr Rev Musculoskelet Med 2013;6(4):294–303. DOI: 10.1007/s12178-013-9173-z
  14. Deland JT, de Asla RJ, Sung IH, et al. Posterior tibial tendon insufficiency: which ligaments are involved? Foot Ankle Int 2005;26(6):427–435. DOI: 10.1177/107110070502600601
  15. Bluman EM, Myerson MS. Stage IV posterior tibial tendon rupture. Foot Ankle Clin 2007;12(2):341–362, viii. DOI: 10.1016/j.fcl.2007.03.004
  16. Abousayed MM, Alley MC, Shakked R, et al. Adult-Acquired Flatfoot Deformity: Etiology, Diagnosis, and Management. JBJS Rev 2017;5(8):e7. DOI: 10.2106/JBJS.RVW.16.00116
  17. Toolan BC, Sangeorzan BJ, Hansen ST Jr. Complex reconstruction for the treatment of dorsolateral peritalar subluxation of the foot. Early results after distraction arthrodesis of the calcaneocuboid joint in conjunction with stabilization of, and transfer of the flexor digitorum longus tendon to, the midfoot to treat acquired pes planovalgus in adults. J Bone Joint Surg Am 1999;81(11):1545–1560. DOI: 10.2106/00004623-199911000-00006
  18. Alshalawi S, Galhoum AE, Alrashidi Y, et al. Medial Ankle Instability: The Deltoid Dilemma. Foot Ankle Clin 2018;23(4):639–657. DOI: 10.1016/j.fcl.2018.07.008
  19. Stein BE, Schon LC. Posterior tibial tendon dysfunction in the adult: current concepts. Instr Course Lect 2015;64:441–450.
  20. Conti MS, Ellis SJ. Weight-bearing CT scans in foot and ankle surgery. J Am Acad Orthop Surg 2020;28(14):e595–e603. DOI: 10.5435/JAAOS-D-19-00700
  21. Deland JT, de Asla RJ, Segal A. Reconstruction of the chronically failed deltoid ligament: a new technique. Foot Ankle Int 2004;25(11):795–799. DOI: 10.1177/107110070402501107
  22. Hintermann B, Valderrabano V, Kundert HP. Lengthening of the lateral column and reconstruction of the medial soft tissue for treatment of acquired flatfoot deformity associated with insufficiency of the posterior tibial tendon. Foot Ankle Int 1999;20(10):622–629. DOI: 10.1177/107110079902001002
  23. Ji Y, Tang X, Li Y, et al. Analysis of 3-dimensional finite element after reconstruction of impaired ankle deltoid ligament. Exp Ther Med 2016;12(6):3913–3916. DOI: 10.3892/etm.2016.3894
  24. Pellegrini MJ, Torres N, Cuchacovich NR, et al. Chronic deltoid ligament insufficiency repair with internal brace augmentation. Foot Ankle Surg 2019;25(6):812–818. DOI: 10.1016/j.fas.2018.10.004
  25. Brodell JD Jr, MacDonald A, Perkins JA, et al. Deltoid-Spring Ligament Reconstruction in Adult Acquired Flatfoot Deformity With Medial Peritalar Instability. Foot Ankle Int 2019;40(7):753–761. DOI: 10.1177/1071100719839176
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